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ROW2012-00022 a Community Development TIGARD Request for Permit Action 3 V/A - $ 979 TO: CITY OF TIGARD Building Division Services Coordinator 13125 SW Hall Blvd., Tigard, OR 97223 Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov FROM: ❑ Owner ❑ Applicant ❑ Contractor [ City Staff (check one) REFUND OR Name: INVOICE TO: (Business or Individual) Mailing Address: City /State /Zip: Phone No.: PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1): [X] CANCEL PERMIT APPLICATION. n REFUND PERMIT FEES (attach receipt, if available). n INVOICE FOR FEES DUE (attach case fee schedule and explain below). n REMOVE CONTRACTOR FROM PERMIT (do not cancel permit). Permit #: ROW2012 -00022 Site Address or Parcel #: In front of 6950 SW Hampton Project Name: Comcast Subdivision Name: Lot #: EXPLANATION: Comcast requests this permit be voided. Signature: JLiktb Date: 3/20/12 Shirley Treat Print Name: Refund Policy 1. The Director or Building Official may authorize the refund of: a) any fee which was erroneously paid or collected. b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended. c) not more than 80% of the land use application fee for issued permits. d) not more than 80% of the building plan review fee when an application is canceled before any plan review effort has been expended. e) not more than 80% of the building permit fee for issued permits prior to any inspection requests. 2. Refunds will be returned to the original Payer in the same method in which payment was received. Please allow 1 -2 weeks for processing refunds. FOR OFFICE USE ONLY Rte to S s Admin: Date B Rte to Date .;, 7 5 Refund Processed: Date By ;; .., Invoice Processed: Date By Permit Canceled: Date /g,r}// By Parcel Tag Added: Date By Receipt # NjA Date • Method Amount $ I: \Building \Forms \RegPermitAction.doc Rev 07/26/07 it AJ6'nQ paegss City of Tigard 0(y) Application For Work In The Right -Of -Way `" ROW Permit FOR STAFF USE ONLY General Information: Right -of -Way on , Property Address/Location(s): 6950 SW Hampton St, Tigard, OR 97223 Case No.: � . 1.)-- 0000, 11 13 Receipt No.: Date: Z1 2'' *Applicant's Name: Comcast - Attn: Scott Sarber Application Accepted By: S -1 Address: 9605 SW Nimbus Ave Revised 7/1/10 City/State: Beaverton, OR Zip: 97008 /wig 3 I/ 31/2. �3ctcr-- i Primary Contact: Scott Sarber REQUIRED SUBMITTAL Phone: (503) 519 -7538 Fax: (503) 605 -6233 INFORMATION Contractor's Name: Tennessee Cable Service , CCB# 77450 Expiration: 10/25/2013 Submit a scaled sketch of the proposed work to be done Address: 2310 E. 2nd St. City /State: Vancouver, WA Zip: 98661 Phone: (360) 696-8900 Fax: (360) 696 -9119 Professional Engineered Plans are required for. Plans By: K &B • Street Widening Address: 4120 SE International Way • Subdivision Infrastructure City/State: Milwaukee, OR Zip: 97222 • Main utility line extension: Phone: (503) 650 -6041 Fax: (503) 650 -7390 L•curpin \masters \land use applications \row app.docx Description of work: Comcast is proposing to directional bore /trench 211' a min. of 36" below grade and place (1) -2" conduit in the City of Tigard right -of -way. Estimated value of work (within the public right -of -way): $ Is work related to a LAND -USE DECISION? YES I I NO I. If so please specify (MLP, SDR, SUB, etc.) case #: Is the work related to a BUILDING PERMIT? YES NO II If so please specify (BUILDING PERMIT) case #: *NOTE: Person specified as "Applicant" shall be designated "Permittee" and shall provide financial assurance for the work. City of Tigard I 13125 SW Hall Blvd., Tigard, OR 97223 I 503 - 718 -2464 I www.tigard - or.gov I Page 1 of 1 • - ' . .e --441 N NOTES: 0 1. ALL WORK AREAS TO BE RESTORED TO LIKE OR BETTER CONDITION. W E 2. ALL OTHER UTILITIES ARE BASED OFF EXISTING LOCATES OR UTILITY " -- ROW S STRUCTURES. - 15• -- 3. IT IS THE CONSTRUCTION CONTRACTORS RESPONSIBILITY 31' FROM SEWER TO CALL FOR LOCATES BEFORE 1L1 �1 1 FROM WATER DIGGING. —FO `� Q 3 7' ROM ROW 6969 A 4. BORE /DRILL SYM. - V i L L. iI I .5■ To S n �, - - }- ROW — — — 5. TRENCH SYMBOLOGY- — W 7 2ND AVE EXISTING CATV PEDESTAL 17 •SW 6. EXISTING CONDUIT - CO) FOC r. Contact: Scott Sarber Title: Fiber Construction Coordinator DIRECTIONAL BORE AND PLACE (1 }2- CONDUIT a Mobile - (503) 519 -7538 A MIN. OF 36 BELOW GRADE Office - (503) 605-6311 (TYPICAL) TO SW 69TH AVE Email - scott_sarber @cabie.comcast.com \ SW HAMPTON ST 60' Bg, fOc \^` ROW - s S ccat. r 5. swFoc 9605 SW Nimbus Ave R0 Beaverton, OR 97008 — — — — — ROW — — — — — — _ B' 1 20' FROM SEWER Q : 4120 SE INTERNATIONAL WAY 1 3' FROM WATER SUITE A7 MILWAUKIE , OR 97222 I TRENCH AND PLACE (112' CONDUIT Email: �„g@�� Design By K B B (503) 650 -6941 A MIN. OF 36 BELOW GRADE (TYPICAL) SITE ADDRESS: 7000 \ • I 6950 SW Hampton St, 5' FROM FOC — 1-- - 1' FROM ROW Tigard, OR 97223 2S1W01NE W REV, DATE DESCRY11DN APPS a I it 1 03107112 CITY OF TIGARD PERMIT DRAWING Q = I }-- CD I-- CO - 1` NEW CATV PEDESTAL / SCALE: PROIECTNUM3flt 1 • = 25' 827090 ' `35' O SHEET NUMBER ..... u � i - � 6950 1 FIBER ENHANCEMENT 24 PERMIT DRAWING 1 j, FILE E: E NAM c __ 7 SHEET OF 1 1 CMTCS -918 -383 j if 'tom w 014076N 4 III ` � I 014076C C) I 01A074C • 014103 0140310 m:130 011033 014013( HAMPTON ST ■ `•01� 3 C 0140 C 1tACO377.0 ■014035( C V e © ssolAO6sT y 1A044 w V 1A a v 5014r0�21yQ01i#039C : fl40`C 10� A�1 i Fccl C 12` ,24W,,) t4. - z